Massive haemorrhage (bleeding) is a life-threatening emergency. It can be distressing for patients, the people important to them, and health and social care professionals. If someone has a massive haemorrhage, they can deteriorate very quickly. It's important to know who is at risk and what the signs are.
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Key points
- Massive haemorrhage (bleeding) is an emergency in palliative care.
- Massive haemorrhage is when a patient loses large amounts of blood and has symptoms of shock.
- Patients can haemorrhage from different parts of the body.
- Find out if someone is at risk of massive haemorrhage and who to call if it happens.
- Get help immediately and call 999 if the patient has a massive haemorrhage.
- Keep calm and explain what’s happening to the patient and those important to them.
- Staying with the patient is more important than leaving them to get medication.
What is massive haemorrhage?
A massive (or major) haemorrhage is when a patient loses large amounts of blood. Rarely, a massive haemorrhage from an artery can cause the patient to die. This is called a terminal haemorrhage.
Patients with a terminal illness may lose small amounts of blood. This is not a massive haemorrhage and is not treated as an emergency. But it may be a warning of a larger bleed. It's important to report any bleeding to the patient's GP, specialist nurse or district nurse.
Patients most at risk of massive haemorrhage
Massive haemorrhage can occur in people with advanced cancer. It may be caused by:
- the tumour itself, for example if cancer spreads into a blood vessel
- whole-body effects of cancer, such as impaired blood clotting.
Patients with other medical conditions, such as liver disease, may also be at risk of haemorrhage.
Surgery or radiotherapy for head and neck cancers increase the risk of bleeding.
Some medications can also increase the risk, including:
- non-steroidal anti-inflammatory drugs (NSAIDs)
- steroids, such as dexamethasone
- anticoagulants (medicines that help stop the blood clotting) including warfarin, aspirin and low-molecular weight heparin.
Signs and symptoms of massive haemorrhage
Signs of bleeding include:
- haemoptysis (coughing up blood)
- haematemesis (vomiting blood)
- melaena (dark, tarry faeces caused by bleeding in the stomach or small intestine)
- haematuria (blood in the urine)
- bleeding from ulcers, tumours or wounds on the skin.
Sometimes bleeding is internal. The patient may have symptoms of shock or lose consciousness very quickly with no obvious source of bleeding.
Talking to patients at risk of massive haemorrhage
The healthcare team will decide whether the patient and people important to them should be aware of the risk of haemorrhage. If they decide they should be told about the risk, the patient's GP, specialist nurse or district nurse should sensitively explain to them what might happen.
Advance care planning
A doctor or nurse should discuss resuscitation with the patient and those important to them. The patient's wishes will be documented in their care plan.
The patient may have recorded their wishes using a Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) form. This summarises how they would like to be cared for in an emergency, including whether they would want to be resuscitated.
ReSPECT operates in many areas of England and Scotland but is yet to be adopted in Wales and Northern Ireland.
If a patient wants to refuse certain treatments in an emergency, they may record this in an Advance Decision to Refuse Treatment (ADRT). This is sometimes called a living will. In Scotland, it's called an Advance Directive.
If a patient does not want cardiopulmonary resuscitation (CPR) if they have a cardiorespiratory arrest, this can be recorded in a Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR) form.
Supporting patients at risk of massive haemorrhage
If a patient is at risk of haemorrhage, there are things you can do to make it less distressing for the patient and those involved in their care:
- Find out what interventions the patient does and does not want if they have a bleed.
- Make sure that all healthcare professionals and services are aware of the person’s care plan, including out-of-hours services.
- Make sure the patient and their carer/s have an emergency contact number.
- Find out if the patient has been prescribed anticipatory medicine, where it’s kept and who to call if it’s needed. This is because a doctor or specialist nurse may prescribe anticipatory medicine to sedate the patient to reduce their distress if they have a bleed.
- Make sure the patient has some dark coloured sheets or towels to help make the bleeding look less obvious.
- Make sure you have a supply of plastic aprons, gloves, and clinical waste bags in case they’re needed to clean up.
If a patient has a massive haemorrhage
If a patient has a massive haemorrhage, do the following things:
- Call for help immediately.
- Call 999 if the patient wishes to be resuscitated (does not have a DNACPR in place).
- If the patient has been prescribed anticipatory medicine and you're qualified to give it, administer sedation. If you're not qualified, call someone who can give it.
- Try to stay calm and reassure the patient and anyone else present.
- Stay with the patient and keep talking to them.
- Put the patient in the recovery position if appropriate.
- If you can, apply pressure to the bleeding point, using dark-coloured towels.
If the patient is clearly dying, it’s important to stay with them until help arrives and provide support and non-pharmacological interventions, rather than trying to give sedative medications. This is because the patient may quickly lose consciousness and may be frightened especially if left alone.
Getting support afterwards
Dealing with a massive haemorrhage can be very distressing for everyone involved. Talk to your manager if you need support afterwards.
You can support the people close to the person by talking about what happened and suggesting they speak to a bereavement counsellor, if appropriate.
You, or anyone else affected by what’s happened, can also contact our free Support Line on 0800 090 2309.